EFTA00313918.pdf

NYU Langone Health NYU Langone Health Notice of Privacy Practices NOTICE OF PRIVACY PRACTICES ACKNOWLEDGME NT FORM By signing this form, I acknowledge that I have receiv ed a copy of NW Langone Health's Notice of Privacy Practices. Patient Name: Ten= kem Signature: Date: Personal Representative's Name (if applicable): Personal Representative's Authority (e.g., parent, guard ian, health care prosy): Effective as of 11101+'2017. EFTA00313918